Letters to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 136–139 J. Hussey* Genitourinary Medicine Department, City Hospitals Sunderland NHS Foundation Trust, Kayll Road, Sunderland SR4 7TP, United Kingdom J. Mansﬁeld M. Gunn Gastroenterology Department, Newcastle Hospitals NHS Foundation Trust, Royal Victoria Inﬁrmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, United Kingdom J. McLelland Dermatology Department, Newcastle Hospitals NHS Foundation Trust, Royal Victoria Inﬁrmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, United Kingdom DR S. Needham Histopathology Department, Newcastle Hospitals NHS Foundation Trust, Royal Victoria Inﬁrmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, United Kingdom po rC *Corresponding author. Tel.: +44 0191 5699021; fax: +44 0191 5699244 E-mail addresses: [email protected] [email protected] (J. Hussey) 19 March 2013 http://dx.doi.org/10.1016/j.ejogrb.2013.10.020 Co pi aa ut or iza was offered a vulval biopsy but declined. Over the next year her problems persisted and she went on to develop perianal oedema and lymphangiectasia. A colonoscopy with terminal ileal biopsies was performed (the colon and terminal ileum were macroscopically normal) along with a vulval biopsy. On histology microscopic foci of inﬂammation with early aphthous ulceration and granulomas were seen in the ileum with inﬂammation and granulomas on the vulval sample too, consistent with a diagnosis of Crohn’s disease. She remains under gastroenterology follow-up and is currently taking azathioprine. A delayed diagnosis, at such a vulnerable age, also contributed to negative feelings and embarrassment for her. Crohn’s disease is a chronic granulomatous inﬂammatory bowel disorder. It has several well-recognised extra-intestinal manifestations such as erythema nodosum, uveitis and arthritis. Vulval involvement is much rarer but is possibly underdiagnosed [1]. It occurs most commonly by direct extension of gastrointestinal disease but more rarely as ‘metastatic Crohn’s disease’ (MCD), where cutaneous granulomatous reactions occur in areas separated from the gastrointestinal tract by normal skin. Metastatic vulval involvement manifests most commonly as labial swelling or induration, but erythema, nodules, papules, plaques, pustules or ulceration have all been seen [2]. It is worth remembering that in 25% of cases of cutaneous involvement, skin changes predate the development of gastrointestinal symptoms by years. This can lead to diagnostic difﬁculty, which is confounded by the fact that MCD is characterised histologically by granulomatous inﬂammation, which carries a broad differential diagnosis (including mycobacterial infections, actinomycosis, lymphogranuloma venereum, syphilis, donovanosis, sarcoidosis and hidradenitis suppurativa) [2]. It has been noted that particularly in the paediatric cohort, vulval oedema caused by MCD is classically non-tender and painless, which may be of some help diagnostically. Even in the absence of gastrointestinal symptoms, both colonoscopy with biopsy (demonstrating non-caseating granulomata) [3] and the use of MRI (with demonstration of skin thickening, subcutaneous oedema, abscess formation or ﬁstulae) [4] may be useful. MRI also has a role in excluding other potential causes of vulval oedema, such as vascular malformations or malignancies. Radiolabelled leucocyte scans have signiﬁcant limitations in the initial diagnosis of Crohn’s disease as histology is not obtained, and faecal biomarkers may now provide a better non-invasive test for bowel inﬂammation [5]. This case illustrates the difﬁculty in early recognition of Crohn’s disease when women present with cutaneous vulvar changes, in absence of active gastrointestinal symptoms. Ultimately a multidisciplinary approach, along with skin and intestinal biopsies secured the diagnosis of this multisystem disease. da 138 References [1] Foo WC, Papalas JA, Robboy SJ, Selim MA. Vulvar manifestations of Crohn’s disease. Am J Dermatopathol 2011;33:588–93. [2] Keiler S, Tyson P, Tamburro J. Metastatic cutaneous Crohn’s disease in children: case report and review of the literature. Pediatr Dermatol 2009;26:604–9. [3] Mun JH, Kim SH, Jung DS, Ko HC, Kim MB, Kwon KS. Unilateral, non-tender, vulvar swelling as the presenting sign of Crohn’s disease: a case report and our suggestion for early diagnosis. J Dermatol 2011;38:303–7. [4] Pai D, Dillman JR, Mahani MG, Strouse PJ, Adler J. MRI of vulvar Crohn’s disease. Pediatr Radiol 2011;41:537–41. [5] Lamb CA, Mansﬁeld JC. Measurement of faecal calprotectin and lactoferrin in inﬂammatory bowel disease. Frontline Gastroenterol 2011;2:13–8. L. Mitchell Genitourinary Medicine Department, Newcastle Hospitals NHS Foundation Trust, New Croft Centre, Market Street East, Newcastle upon Tyne NE1 6ND, United Kingdom Ureaplasma parvum peritonitis after oocyte retrieval for in vitro fertilization Dear Editor, Ultrasound-guided transvaginal oocyte retrieval (TVOR) during in vitro fertilization (IVF) is a simple procedure, but not without risk. Complications are rare but can be serious. The most frequent ones are vaginal bleeding and pelvic infection. We report here an unusual case of peritonitis caused by Ureaplasma parvum after oocyte retrieval for IVF. In March 2010, 72 h after oocyte retrieval for IVF was performed, a 34-year-old woman was hospitalized for severe pelvic pain mainly in the right iliac fossa, with fever of 39 8C for the last 24 h. The couple had undergone oocyte retrieval for male factor infertility. The patient received antimicrobial prophylaxis at the time of TVOR (cefoxitin 2 g, one intravenous injection). On admission, physical examination revealed guarding in the right iliac fossa, predominant right lumbar pain and the presence of leukocytes and nitrites on the urine dipstick test. Laboratory testing showed a biological inﬂammatory syndrome with a leukocytosis at 9350 neutrophils/mm3 and C-reactive protein at 202 mg/l. The patient was treated with ceﬁxime 200 mg 2 per day. Pelvic ultrasound performed on the following day showed a pelvic ﬂuid collection in the pouch of Douglas and a periappendiceal collection suggestive of acute appendicitis. As her clinical condition failed to improve, an exploratory laparoscopy was performed in the digestive surgery department at the Bordeaux University Hospital. A retro-uterine pelvic collection of pus was found without inﬂammation of the appendix. The abscess was drained and bacteriological specimens were taken (deep pus and false membranes). 14/07/2014 Letters to the Editor—Brief Communication / European Journal of Obstetrics & Gynecology and Reproductive Biology 172 (2014) 136–139 References [1] Waites KB, Be´be´ar CM, Roberston JA, Talkington DF, Kenny GE, editors. Cumitech 34, Laboratory diagnosis of mycoplasmal infections. Washington, DC: American Society for Microbiology; 2001. [2] Govaerts I, Devreker F, Delbaere A, Revelard P, Englert Y. Short-term medical complications of 1500 oocyte retrievals for in vitro fertilization and embryo transfer. Eur J Obstet Gynecol Reprod Biol 1998;77:239–43. [3] Roest J, Mous HV, Zeilmaker GH, Verhoeff A. The incidence of major clinical complications in a Dutch transport IVF programme. Hum Reprod Update 1996;2:345–53. [4] Waites KB, Talkington D. New developments in human diseases due to mycoplasmas. In: Blanchard A, Browning GF, editors. In mycoplasmas: pathogenesis, molecular biology, and emerging strategies for control. Wymondham: Horizon Bioscience; 2005. p. 289–354. [5] Yager JE, Ford ES, Boas ZP, et al. Ureaplasma urealyticum continuous ambulatory peritoneal dialysis-associated peritonitis diagnosed by 16S rRNA gene PCR. J Clin Microbiol 2010;48:4310–2. C. Be´be´ara,b Univ Bordeaux, USC EA 3671 Mycoplasmal and Chlamydial Infections in Humans, Bordeaux, France b CHU de Bordeaux, Laboratoire de Bacte´riologie, Bordeaux, France DR a po rC V. Grouthier C. Hocke´ CHU de Bordeaux, Centre Alie´nor d’Aquitaine, Service de Me´decine et de la Reproduction, Bordeaux, France C. Jimenez A. Papaxanthos CHU de Bordeaux, Centre Alie´nor d’Aquitaine, Laboratoire de Biologie de la Reproduction, Bordeaux, France Conﬂict of interest None. Co pi aa ut or iza da Blood cultures performed on admission were negative and cyto-bacteriological examination of the urine showed Escherichia coli, sensitive to b-lactams, at 106 colony-forming units/ml. However, purulent ﬂuid and false membrane specimens collected during laparoscopy revealed U. parvum at 102 colony-forming units/ml, identiﬁed by culture and real-time PCR [1]. Antibiotic susceptibility testing conﬁrmed that the U. parvum was susceptible to tetracyclines and ﬂuoroquinolones. Chlamydia trachomatis and Mycoplasma genitalium nucleic acid ampliﬁcation tests and other bacterial cultures were negative from the laparoscopic specimens. Sperm cultures from her husband two months before and after the oocyte biopsy were negative for urogenital mycoplasmas. Antibiotic treatment was changed for intravenous ticarcillin, clavulanic acid and ciproﬂoxacin, and was changed to oral administration after 48 h of apyrexia. The outcome was completely successful after 21 days of antibiotic treatment. The rate of short-term medical complications during IVF is low, and post-operative infections are reported in less than 0.5% of cases [2,3]. Ureaplasmas, Ureaplasma urealyticum and U. parvum, can be isolated from the lower genital tract in many sexually active adults (30–70% in healthy women), leading to difﬁculty in accepting these organisms as independent causes of disease. Nevertheless, Ureaplasma spp. can cause non-gonococcal urethritis in men, pelvic infectious diseases, infections during pregnancy and neonatal infections [4]. U. urealyticum is mostly involved in non-gonococcal urethritis while U. parvum more frequently colonizes the vagina and is therefore more involved in women’s disorders. This report represents the ﬁrst case of U. parvum peritonitis after IVF, with the ureaplasma directly grown from a peritoneal specimen. Very few cases of Ureaplasma spp. peritonitis have been described in the literature, and most of them were described in association with continuous ambulatory peritoneal dialysis [5]. The organism may have gained access to the peritoneum via direct inoculation during the oocyte retrieval. The patient’s vagina was probably colonized by U. parvum, but no vaginal specimen was obtained at the time of the puncture. The present report demonstrates the ability of U. parvum to cause peritonitis in the setting of IVF. It seems important to look for this microorganism, especially in cases of ‘‘negative-culture’’ peritonitis, as Ureaplasma spp. requires speciﬁc culture media. Molecular diagnostic methods can be valuable in this clinical setting. 139 H. Creux* CHU de Bordeaux, Centre Alie´nor d’Aquitaine, Service de Me´decine et de la Reproduction, Bordeaux, France *Corresponding author at: Service de Me´decine et de la Reproduction, Centre Alie´nor d’Aquitaine, Hoˆpital Pellegrin, 33076 Bordeaux, France. Tel.: +33 556796033 E-mail addresses: [email protected] (H. Creux) [email protected] (C. Be´be´ar) 26 July 2013 14 October 2013 Accepted 25 October 2013 http://dx.doi.org/10.1016/j.ejogrb.2013.10.025 14/07/2014